Chest Trauma

19thApril 2013

Kenyatta National Hospital

Dr. Josiah Ruturi

Thoracic and Cardiovascular Surgeon .

- Approximately 150,000 people die each year in the United States as a result of trauma.

- 25% of the deaths can be directly related to thoracic injury.

- Almost all patients with thoracic trauma are treated conservatively with a successful outcome.

- urgent operative treatment was required in only:

- 0.5% of blunt thoracic injuries.

- 2.8% of penetrating thoracic injuries .

OBJECTIIVES Identify and initiate treatment of life-

threatening thoracic injuries Primary survey Secondary survey Procedures Special considerations

Immediate Life-Threatening Injuries

Airway obstruction Tension Pneumothorax Open Pneumothorax Massive Hemothorax Flail Chest Cardiac Tamponade

Potentially Life-ThreateningInjuries:

Pulmonary Contusion Myocardial Contusion Aortic Disruption Traumatic Diaphragmatic Rupture Tracheobronchial Disruption Esophageal Disruption

An unstable hemodynamic state :

1. Traumatic cardiac arrest or near arrest and

an Emergency department thoracotomy.

2. Cardiac tamponade

3. Persistent ATLS class III shock despite fluid

resuscitation (blood loss 1500–2000 mL, pulse rate > 120,

blood pressure decreased)

4. Chest Tube output > 1500 mL of blood on insertion

5. Chest Tube output > 500 mL/hour for the initial hour

6. Massive hemothorax after chest tube drainage

Primary Survey

Airway: patency, retractions, obstruction

Breathing: exposure, rate, pattern, cyanosis

Circulation: *Pulses, color, *neck veins, monitor for arrythmias

*hypovolemic patients might not exhibit

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Initial Management Airway - with cervical spine control -

tracheobronchial tree disruption Breathing - tension/open pneumothorax,

flail chest, lung contusion Circulation - cardiac tamponade,

hemothorax, cardiac contusion, aortic disruption

Specific signs and symptomsPneumothorax

Tension Pneumothorax– Hypotension, tracheal deviation, distended

neck veins Pneumothorax

– No signs, tachypnea, tachycardia, decreased breath sounds, hyperresonance, SQ emphysema

Pneumomediastinum– Hamman’s sign, SQ emphysema

Subcutaneous Emphysema

Airway, Lung or Blast injury esophageal injury: Boerhaave’s Adjacent penetrating wound Progression to tension pneumothorax

Pneumothorax

Pneumothorax-Treatment

<15% -very small spontaneous can be given 100% O2 in ED and observed

<25% - simple pneumothorax can be aspirated through a small catheter

Larger pneumothoraces/ underlying lung dz –tube thoracostomy

Pneumonediastinum – conservative

Tension Pneumothorax

“one-way valve”: air enters, can’t exit

displacement of mediastinum/trachea

decreases venous return, displaces opposite lung

Causes: spontaneous pneumothorax, blunt chest trauma, penetrating trauma

Tension Pneumothorax

Left Right

A: Air under tension in left thorax

A

B

B: Collapsed right lung

Pleural margin; partial lung

collapse

Tension Pneumothorax

Heart

LeftRight

B

B

B: pressure of tension pneumothorax pushing midline structures (heart, mediastinum) into patient’s left thoracic cavity

A

A: air, under tension, in thoracic cavity

Tension Pneumothorax

Clinical manifestations in patient with– Spontaneous breathing – Respiratory distress– Florid face– Tracheal deviation– Distended neck veins– Tachycardia– Hypotension

Needle Thoracentesis Indication: Rapidly deterioration with

tension pneumothorax. Equipment

– Povidone-iodine solution– 14-gauge catheter-over-needle device

Technique– Cleanse overlying skin– Insert needle at 2nd or 3rd intercostal space,

midclavicular line, over top of rib– Leave catheter in pleural space open to air

Sucking Chest Wound

AKA communicating pneumothorax Large defects: if opening > 2/3

trachea, air will pass preferentially. Cover immediately with cleanest

occlusive dressing 3 sides vs 4 sides

Massive Hemothorax

>1500 cc blood Mechanism:

– Penetrating injury of systemic or hilar vessels, especially wounds medial to nipples, scapulas.

– Blunt trauma Loss of Breath sounds, dullness to

percussion

Flail Chest

No bony continuity with rest of cage Multiple rib fractures, paradoxical

movement Hypoxia from injury to underlying

lung 30% missed in first 6 hours

Flail chest is a marker for significant injuries

Retrospective analysis, 92 pat, L-1 center. 46% had pulmonary contusion 70% had pneumo or hemothorax Great vessel, tracheobronchial injuries had no

associated. 27% developed ARDS 69% required mechanical ventilation 33% mortality

Ciraulo DL et al. J Am Coll Surg 1994;178(5):466. (Penn)

Traumatic Aortic Injury

Retrosternal/intrascapular pain Dyspnea, hoarseness, dysphagia,

HTN Pseudocoarctation syndrome Hypotension Harsh systolic murmur (AI) 50% without external findings

Cardiac Tamponade

Penetrating injuries most common Beck’s Triad Kussmaul’s sign (rise in CVP with

inspiration) Mimic: tension pneumo on left side EKG: electrical alternans (rare)

Management of Tamponade:

Cautious fluid management Pericardiocentesis: 15-20 cc may

immediately improve hemodynamics Open thoracotomy and inspection

Pericardiocentesis

Indications– Immediate threat to life– Severe hemodynamic impairment– Fall in systolic blood pressure >30 mm

Hg

Pericardiocentesis

Technique– Patient in supine position, upper

torso elevated– ECG limb leads attached to patient– Use echocardiography guided procedure

(rarely: ECG-guided, V lead)– Subxiphoid approach– Continuous aspiration

Pulmonary Contusion

Determinants of outcome ISS > 25 Initial GCS < 7 Transfusion > 3 U blood pO2/FiO2 < 300 Not correlated to shock or IV fluid administration Extent of contusion seen on initial chest X-ray

not predictive of mortality or intubation.

Johnson JA et al. J Trauma 1986; 26(8):695.

Diaphragmatic Rupture

Blunt trauma: large tears Penetrating: small tears, subtle More commonly diagnosed on the

left

Tracheobronchial Tree

Larynx– Hoarseness– Subcutaneous emphysema– Palpable Fracture– Crepitus

Trachea:– Noisy breathing– Penetrating injuries: esoph, carotid artery,

jugular vein trauma

Scapular and Rib Fractures

Splinting impairs ventilation Majority – optimise pain mx Scapula, often indicate major injury to the

head, neck, spinal cord, lungs and great vessels: mortality > 50%

pain, tenderness, crepitus

Sternal Fractures

Mortality 25-45% Underlying injuries to myocardium Flail segment

Penetrating Cardiac Injury

Ventricles: will self seal more commonly

RV>LV>RA>LA 56-66% overall survival 87% survival in OR thoracotomy Positive predictors: VS on admission,

short transport, SW

penetrating cardiac injury A combination of: - unstable patient: aggressive operative intervention - stable patient: ultrasound evaluation

provided an overall survival of 40% in the patients with known cardiac injury.

The diagnosis of a traumatic pericardial effusion can be made by the visualization of an echolucent region between the heart and pericardium,

right ventricular diastolic collapse will confirm tamponade.

ultrasound imaging appears to be with an accuracy, sensitivity, and specificity that exceeds 95%

Classification of Mediastinal Injuries

M1= base of the neck into mediastinum or pleura M2= one pleural cavity and mediastinal violation (central hematoma, visceral or spinal cord injury,metallic fragments in the mediastinum) M3 = parasternal injury within the nipple line or < 4 cm from the sternumM4 = two pleural cavities and mediastinal traverse.

M4 - All of the mediastinal traverse injuries were caused by gunshot wounds - this trajectory had the highest rate of instability and subsequent operative intervention. - the highest observed mortality rate (60%), M1 - Injuries from a cephalad direction were predominately stab wounds. - were responsible for the second highest incidence of instability and subsequent operative intervention.

The presence of a gunshot wound, was associated with significant risk of both instability and death.

Penetrating Chest Trauma

Low chest SW: 15% intraperitoneal, 15% require operative intervention

(diaphragm)

Pediatric Chest Trauma

Compliance = internal injury Mobility = tension pneumos, flail

chest Bronchial and diaphragmatic injuries Infrequent injuries to great vessels

Summary

Thoracic trauma is common in multiply injured patients

Life- threatening problems may be temporarily relieved by simple measures

Injury recognition important High index of suspicion for occult injuries